Rural age‐friendly ecosystems for older adults: An international scoping review with recommendations to support age‐friendly communities

Abstract Background and Aims The population of older adults in rural areas is rising, and they experience higher rates of poverty and chronic illness, have poorer health behaviors, and experience different challenges than those in urban areas. This scoping review seeks to (1) map the state of the science of age‐friendly systems in rural areas regarding structural characteristics, processes for delivering age‐friendly practices, and outcomes of age‐friendly systems, (2) analyze strengths, weakness, opportunities, and threats of age‐friendly system implementation, and (3) make person, practice, and policy‐level recommendations to support active aging and development of age‐friendly communities. Methods An international scoping review was conducted of articles that used age‐friendly framing, had a sample age of 45 years of age or older, self‐identified as rural, and reported empiric data. Searches were conducted in PubMed, CINAHL, AgeLine, PsychINFO, EMBASE, Scopus, and Academic Search Elite on October 26, 2021, and rerun March 10, 2023. Data were charted across three analytic layers: socioecological model, Donabedian's framework, and SWOT analysis. Results Results reveal limited data on outcomes relevant to organizations, such as return on investment or healthcare utilization. While the SWOT analysis revealed many strengths of age‐friendly systems, including their impact on persons' outcomes, it also revealed several weaknesses, threats, and gaps. Namely, age‐friendly systems have weaknesses due to reliance on trained volunteers and staff, communication, and teamwork. System‐level threats include community and health system barriers, and challenges in poor/developing areas. Conclusions While age‐friendly systems in this review were heterogeneous, there is an opportunity to focus on unifying elements including the World Health Organization age‐friendly cities framework or 4Ms framework for age‐friendly care. Despite the many benefits of age‐friendly systems, we must acknowledge limitations of the evidence base, pursue opportunities to examine organizational metrics to support implementation and sustainability of age‐friendly systems, and leverage improvements in age‐friendliness at a community level.


| INTRODUCTION
Age-friendly as a concept has evolved from its beginnings in the early years of the 21st century. In 2006, the World Health Organization developed an action plan focused on improving the lives of older adults (age 65 and older) across the globe by identifying how communities could become "age-friendly" and encourage active aging, the process of optimizing opportunities for health, participation, and security to enhance quality of life as people age. 1,2 This led to a worldwide movement and ecosystem encompassing age-friendly policies, public health systems, universities, cities, states, and health systems. 3 The importance of age-friendliness and the growing body of literature surrounding age-friendly communities is evidenced by a recent special issue in a major gerontology journal specifically focused on examining "age-friendliness" at the intersection of person and environment, aging in place, and measurement. 4 The issue, international in scope, is an important representation of the state of the science related to real-world age-friendly initiatives. One omission in the special issue and the extant literature is a thoughtful global synthesis of the rural age-friendly empiric literature. Current reviews of the rural age-friendly literature are either outdated and contain a smaller number of studies, 5,6 or are more recent but focused on a single country. 7 A more recent review does focus on application of individual concepts from the WHO age-friendly cities framework (e.g., healthcare or housing for older adults), but omits projects that truly apply an age-friendly framework. 8 Examining age-friendly systems, systems (cities, communities, or organizations) which support active aging, engagement/participation, and well-being of older persons and their caregivers, in rural areas is critically important. The National Rural Health Association reports that 18% of the United States of America rural populations (vs. 12% urban) are comprised of adults aged 65 and older. 9 The most recent United States of America (USA) census shows that more than 50% of older adults in some states live in rural areas. 10 Reasons for rising populations of older adults in rural areas in the United States of America may include attraction to retirees and movement of younger populations to urban areas for education, work, and social life. 11 Similar movement to and from rural areas have been observed in Europe, 12 and the World Bank and World Urbanization Prospects report rising trends of older adults in rural areas worldwide. 13,14 Further, older adults in rural areas experience higher rates of poverty and chronic illness coupled with poorer health behaviors, when compared with urban areas. 9,15 Developing an age-friendly system requires local level engagement and support to assess needs and prioritize interventions that promote older adults' health and ability to age in place. 16 Persons living in rural communities experience different challenges than those living in metropolitan communities regarding access to affordable housing, transportation, healthcare, and community services. 17 Taken together, this suggests that a careful examination of rural age-friendly systems is needed. Therefore, the purpose of this project is to conduct an international scoping review of the empiric literature on the rural age-friendly ecosystem. This scoping review seeks to (1) map the state of the science of age-friendly systems in rural areas regarding structural characteristics, processes for delivering agefriendly practices, and outcomes of age-friendly systems, (2) analyze strengths, weakness, opportunities, and threats of age-friendly system implementation, and (3) make person, practice, and policylevel recommendations to support active aging and development of age-friendly communities.

| METHODS
In this scoping review, we mapped the empiric literature on the rural age-friendly ecosystem. We selected a scoping review over other types of reviews because it best aligns with the objective of summarizing the quantity and characteristics of the literature by design and other key features. 18 We first developed a protocol for the review, which included a working objective, methods, and proposed timeline and tasks. The team included several experts in conducting reviews and used a consensus model in creating the protocol.

| Identifying the research question
In keeping with Arksey and O′Malley methodology 19 we began with a broad, generalist research question: "What empiric evidence is available for age-friendly ecosystems in rural areas?" Through multiple meetings with the research team, the scope of inquiry was clarified as suggested by Levac et al. 20 by defining the concept of age-friendly, providing rationale for a focus on rural populations exclusively, and the outcomes of interest-studies which reported empiric data. This resulted in a refined question of "What empiric evidence exists which supports age-friendly ecosystems in rural areas?"

| Identifying relevant studies
In this second stage, the focus was on developing a decision plan for our literature search with an emphasis on being as comprehensive as possible. This began with a series of meetings between the team leader (H. B.) and a health sciences librarian with expertise in systematic searches to discuss the scope of the project and strategies available to answer our research question.

| Inclusion/exclusion criteria
Comprehensive inclusion criteria were agreed upon and required that any accepted papers must use an "age-friendly" framing or model. Progenitor terms such as "elder friendly" or associated terms such as "patient priorities care" were accepted. Additional criteria included human studies, sample age of 45 years of age or older (to assure only adult studies), papers self-identified as rural and reported empiric data (quantitative or qualitative). Studies were excluded if not using age-friendly framing; meta-analyses and systematic reviews were also excluded.

| Title and abstract
The title/abstract screening used a hybrid of human-and technologyscreening processes. After the team was trained on the inclusion and exclusion criteria and use of the spreadsheet for the title/abstract screen, four team members (D. L., S. T., S. M., E. G.) screened 25% of the studies per member for exclusion criteria in the human screen.
One team member (L. N.) then conducted a random 20% reliability check, which resulted in 93.5% (72/77) agreement. In the technology round, term identification (e.g., methods, sample, or data) in the spreadsheet was used to identify studies meeting the inclusion criteria of empiric studies. When in doubt, a paper was retained for the next level of screening. For example, 25 papers that did not include an abstract were automatically advanced to full text screening if inclusion/exclusion criteria were not clear from the title.
Inclusion criteria of age and rural were confirmed during the full text screening. A 100% reliability check was conducted on this set of papers and any discrepancies were justified during team meetings.

| Full-text screening
Ten team members (D. L., A. K., J. B., S. T., S. M., E. G., N. C., S. J., L. N., H. B.) conducted a full text screening and data extraction (7−11 articles per team member). Once again, a 100% reliability check was conducted resulting in each paper being examined by at least two people. Effort was made to give each screener a new set of papers from their previous screen. The inclusion/exclusion criteria were applied again before any extraction took place. Forty papers met the protocol criteria and advanced to data extraction.

| Data abstraction and management
Using the study protocol, a second spreadsheet was developed which included the data elements necessary to answer our research question. The full team went through a hands-on training session covering definitions for each data element, reviewing an example paper which had undergone full extraction, and then a practice group extraction. Five study domains (publication, study design, analysis elements, intervention elements, and study outcomes) were assessed. 2.5 | Collating, summarizing, and mapping the results Following Arksey and O′Malley's methodology, 19 we developed a meta synthesis codebook, since descriptive-analytic techniques are used for this narrative review type of analysis. 21 The improvement projects. 23 Each data element was adjudicated using Donabedian's model to identify whether the data element addressed structural characteristics, processes for delivering agefriendly practices, or outcomes of age-friendly systems by socioecological level to identify specific gaps in evidence. Finally, a SWOT analysis allowed us to compare internal (strengths, weaknesses) and external (opportunities, threats) factors identified by articles included in this synthesis that impact implementation and sustainability of age-friendly systems in rural areas. 24 As a final step, the socio-ecological model was collapsed into two categories (person vs. system-level) to develop a clear map of the results and examine strengths, weaknesses, opportunities, and threats across these two categories.

| Study characteristics
Most of the included studies (N = 70) were conducted in five countries: the United States of America (n = 23), Canada (n = 13), China (n = 7), the Netherlands (n = 7), and Australia (n = 5) ( Table 1). The most common study designs were quantitative (n = 28), qualitative (n = 25), mixed methods (n = 8), and implementation (n = 8) studies. Units of analysis included older adults/adults (n = 41), clinicians/healthcare providers (n = 12), service (e.g., community) providers (n = 7), caregivers/family (n = 3), government agencies/employees (n = 3), age-friendly F I G U R E 1 PRISMA 2020 flow diagram for identification and screening of studies. *Searches were rerun on March 10, 2023, and resulted in an additional 131 non-duplicate articles. Of these, 30 articles were deemed eligible for inclusion. Therefore, the final number of studies included in this review were 70 leaders or committee members (n = 3), communities (n = 3), students (n = 1), and health systems (n = 3). Forty-eight studies used the World Health Organization age-friendly cities framework, 10 studies used the 4Ms framework for age-friendly care, and 10 studies did not report a guiding framework. Specific information about study samples and purposes can be found in Table 1.
3.2 | Structural factors, processes, and outcomes of age-friendly systems in rural ecosystems

| SWOT analysis of age-friendly system implementation and sustainability in rural areas
Strengths, weaknesses, opportunities, and threats of age-friendly system implementation and sustainability in rural areas are summarized at the person and system level ( Table 2).

| Summary
Three key takeaways became clear from this qualitative synthesis. • Informal practices such as collective interdependencies and roles strengthen capacity to enhance age-friendliness 57 • Sense of community is a sustainability facilitator 81 • Consider cocreation with older adults 46,85 • Photo-elicitation as opportunity to promote AFS development 57 • Clinicians acknowledge benefits of providing care within AFS 60 • Cross-cultural considerations in AFS 74 and age-friendly surveys 33,71 • Perceptions of age-friendliness 27 • Exercise and recreational facilities associated with lower depression 59 • Validated tool for AFS environment assessment 55,73 and community level indicators for AFS develped 53 • AFS resulted in reduced length of stay and direct costs 32 • Age-friendly features associated with perceived age-friendliness of community 46,57 • AFS result in improved medication management, advanced care planning, and fall risk assessment 83 • Dependence on volunteers 32,71 and staff training 81 • Issues of scope, reach, and sustainability 79 • Common AFS survey overestimated communities age-friendliness 33 • Community characteristics did not impact life satisfaction and selfperceived health 64 • Rural/urban divide in environmental impact 68 • Integrate AFS into existing structures 86 and funding priorities 67 • Congruence between existing practices and AFS 86 • Increase clinician preparedness for AFS with workshop 83 • Accessibility and informal practices underpin community responses to supporting older persons 57 • Community history and identity impact AFS 83 • Walkability and transportation available in communities 35 • Incorporation of 4Ms into the annual wellness visit 67 • Implementation strategies for AFS 75,80 • Community events to boost older adult engagement in AFS 86 • Organizations can work together in AFS 73 • Education, environment, staffing, policies, and other research projects as factors influencing organizational readiness for change 5 • Community planning critical 68 • Community barriers: getting started, minimal diversity, 68 financial constraints, 32,71 collaboration between organizations, 27 Jurisdictional fragmentation 81 • Readiness of service providers to meet the emerging social participation needs of older persons 46 • • Challenges in implementing AFS in poorer communities 84 and WHO organizational domains do not apply well in developing areas 80 • Environment needs to adapt to older adults 46 : pedestrian crossings, special queues, 53 buildings and transportation 33,85 • AFS should include sensory, physical, and sociocultural factors 53 • COVID-19 presented new barriers to AFS 28 Abbreviations: AFS, age-friendly system; WHO, World Health Organization.
processes for delivering age-friendly practices. Least common was data on outcomes of age-friendly systems in the rural ecosystem, especially at the interpersonal and organizational level. While the SWOT analysis revealed many strengths, including its impact on persons' outcomes, 27,32,45,53,59,64,67,69,79,90 and opportunities for agefriendly systems in rural areas, it also revealed several weaknesses, threats, and gaps.

| DISCUSSION
The purpose of this review was to map the state of the science on rural age-friendly systems and make person, practice, and policy-level recommendations to support active aging and development of agefriendly communities. Overall, much work remains to be done in this important area. The unifying element in this scoping review was the focus on the rural age-friendly ecosystem. Further, it was discovered that while many terms and places were identified in this review, agefriendliness was framed in similar ways. The most common framework for age-friendliness in articles in this review was the

| System level weaknesses and threats
Because most of the articles in this review involved quality improvement projects, we completed a SWOT analysis of agefriendly system implementation and sustainability in rural areas.
While the SWOT analysis revealed many strengths, it also revealed several weaknesses, threats, and gaps. Age-friendly systems have weaknesses due to reliance on specially-trained volunteers 77

| Practice
Challenges for implementation and sustainability of age-friendly systems in practice include often limited funding and differences in impact observed in urban versus rural areas. 91 To address funding limitations, one article in this review describes opportunities for setting funding priorities around age-friendly systems. 41  concern is actual and projected increase in the old age dependency ratio worldwide, which indicates increasing proportion of individuals age 65 per individuals who are in the working age population (e.g., 15−64). 104 These trends, combined with higher disease burden 105 and functional decline 106 in older adults, contributes to concern about infrastructure and resources available to meet the needs of our aging populations. Viewing these challenges through a public health lens presents an opportunity for connecting and coordinating sectors and professions that provide services and infrastructure to promote healthy aging, increase access, and identify gaps. 101 To increase support for age-friendly systems, this review reveals the need for more data and information on implementing age-friendly systems across institutions and communities in the rural ecosystem and the impact of various types of age-friendly systems at a person and system level.

| Policy
Policy recommendations of this work begin with the need to promote opportunities to leverage improvements in age-friendliness at a community level. Age-friendly systems are commonly established and maintained at the community level, so that interventions fit with local needs. One challenge with both increasing older adults' access to existing community services and increasing collaboration or shared services between rural communities is transportation and availability of transportation services. 107 Policy focused on increasing agefriendly transportation infrastructure is needed to improve community connections among rural older adults. In addition, improvements in rural technology infrastructure can assist connecting older adults to existing community and healthcare services. This review identified specific challenges in low resource areas. Therefore, future research should consider cost/funding, existing infrastructure, and specific potential benefits of age-friendly systems in low resource areas.

| Limitations
Our literature search was limited to articles published in English only.
The decision to preclude a "gray" literature or a comprehensive bibliography review was made given the involvement of an expert health sciences librarian, multiple test searches, use of multiple databases, and detailed inclusion/exclusion criteria. In addition, we targeted main sources and types of evidence to identify key concepts in the body of literature. 108 Therefore, inclusion of other less rigorous sources of information were deemed more likely to yield additional early work (before publication in a peer-reviewed journal) that would not significantly impact findings of this review. Choice of search terms and inclusion/exclusion criteria could also be considered a limitation, as some articles relevant to our purpose might have been missed. For example, publications from only five countries were identified in this review, which could reflect limitations of the literature searches conducted for this review or of the overall evidence base. However, we used a variety of progenitor terms related to "age-friendly," and this process was completed with a health sciences librarian with expertise in systematic searches.

| CONCLUSIONS
This international scoping review maps the science on rural agefriendly systems and makes person, practice, and policy-level recommendations to support active aging and development of agefriendly communities. While age-friendly systems in this review were heterogeneous, there is an opportunity to focus on unifying elements including the World Health Organization age-friendly cities framework or 4Ms framework for age-friendly care. This article summarizes many potential barriers (community and health system barriers, readiness for change, adapting to needs of older adults) and facilitators (integration of age-friendly systems into existing structure and practices) to consider when implementing and sustaining an agefriendly system in rural areas. Despite the many potential benefits of age-friendly systems in healthcare systems and communities, we must acknowledge limitations of the evidence base, pursue opportunities to examine organizational metrics to support implementation and sustainability of age-friendly systems, and leverage improvements in age-friendliness at a community level.

CONFLICT OF INTEREST STATEMENT
The authors declare no conflict of interest.

TRANSPARENCY STATEMENT
The lead author Daniel Liebzeit affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

DATA AVAILABILITY STATEMENT
We have included relevant protocol/codebook as supplementary material for our scoping review.